Information Collection

OCR Pre-granted Automation Project

IC 10370 under ICR 201403-0945-001 · OMB 0945-0006.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
21138 ID_Civil Rights Infomation Request Form for Medicare Certification Form FINAL 03-19-14.docx	Other-form
21138 ID_ASSURANCE OF COMPLIANCE FORM 03-19-14.docx 21138 ID_ASSURANCE OF COMPLIANCE FORM 03-19-14	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 80

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-form			21138 ID_Civil Rights Infomation Request Form for Medicare Certification Form FINAL 03-19-14.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,900	2,900
Annual IC Time Burden (Hours)	23,200	23,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
21138 ID_ASSURANCE OF COMPLIANCE FORM 03-19-14	21138 ID_ASSURANCE OF COMPLIANCE FORM 03-19-14.docx	03/26/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.